What is Schizophrenia?

Schizophrenia is a mental disorder. The prominent feature is a disturbance in reality testing. Sometimes, these patients are not able to differentiate what is real or not. The common symptoms are firm beliefs such as someone trying to spy on him. He may hear voices or see things. In addition, an oddity of behavior is also common. Schizophrenia is unduly attributed to aggression and dangerousness. That is not the case. This illness is long-standing and will persist for years. If not treated properly, further complications will arise such as aggression or decreased self-care. Another complication of delay in treatment is the marked decline of cognitive functions. Recent studies strongly suggest diagnosing it early and starting treatment as soon as possible. The main benefit of treatment is a good recovery from illness.  

Five core Schizophrenia Symptoms

 

1. Problems of thoughts/ Delusions

A patient develops a firm belief. Sometimes, this is understandable, and sometimes not. Few examples for given below. Example 1; Paranoid delusions A patient starts believing that other persons are against him, they are trying to kill him, they follow him through hidden cameras, they poison his food, etc. but actually, there are no such threats. As a result, the patient becomes fearful and usually refuses to take food because of the fear that someone poisoned it, sometimes patient start keeping weapons as self-defense against the assumed threat. Example 2; delusions of control A patient starts believing that some other person or party is controlling him. They can control his thoughts actions and feelings.

2. Problems of perception/ Hallucinations

This means hearing voices and seeing an object in absence. For example, if the patient hears voices that command him to do certain things we call these Commanding Hallucinations. Other content of voices can be insulting, threatening, and giving comments on patients’ actions. Similarly, patients can see objects or persons in their absence. Remember, these hallucinations are vivid, delineated, and as clear as a real image. Sometimes, we observe that the patient is talking to himself (self-talking), but actually, he may be talking to the voices that are only heard by him The above two symptoms are also called positive symptoms of schizophrenia.

3. Behavioral problems

The oddity of behavior includes talking to himself, smiling to himself, making bizarre gestures and movements, and wearing clothes that are not appropriate for the weather. These problems also vary from patient to patient. Some can be abusive and violent, others isolate them. All these symptoms result in a marked decline in functioning, at work, at school, or home

4. Irrelevant Talk:

You will observe that schizophrenia patients are talking irrelevantly. In this case, they cannot stay on topic. Sometimes they jump from one topic to another without having any connection to them. We call this “loosening of association.” Sometimes they tell undue details about a single topic, we call this “circumstantiality.”

5. Negative symptoms:

These include social isolation, decreased communication, and apathy, blunt and emotionless expressions.

What are Schizophrenia Causes?

There are multiple factors. And they can have a cumulative effect. Usually, a single factor can’t cause schizophrenia.

1. Genetics:

Studies have proven that genetics play a key role in the development of schizophrenia. A lot of genes are identified that can be associated with this disorder. The risk of developing schizophrenia increases by 10% in 1^st-degree relatives. For monozygotic twins, this is 50%

1. Brain changes: (H3)

Some brain areas are found to be shrunken in patients with schizophrenia such as the hippocampus and prefrontal cortex. The ventricles of the brain are dilated.  And there are certain chemicals whose level is increased in the brain such as dopamine and serotonin. And these two brain changes are the target of drugs used to treat schizophrenia

1. Birth and early childhood experiences

Chances of developing schizophrenia are increased in those who experienced difficult labor, birth trauma, head injury, child abuse, and child neglect. Surprisingly maternal influenza infection in the mid-trimester increased of risk of developing schizophrenia to 7 fold in children. Maternal malnutrition; Children who are born to mothers whose nutrition was deficient during early pregnancy, they were more likely to develop schizophrenia later in life. Parental age; the risk of development of schizophrenia is also related to the age of parents at birth. As the parental age increases, the risk increases. According to one study, the chances of developing schizophrenia increase by 50% with every ten-year increase in parental age.

1. Family’s causative role in schizophrenia:

Two types of pathological family patterns have been observed. Marital skew means one parent is extremely dominant, especially the mother, and has eccentricities in her behavior and the other parent has to adjust to these eccentricities. Marital schism; both parents maintained different views and the child has to decide between the loyalties of the parents. These abnormalities are found to be a cause of schizophrenia rather than a result of schizophrenia  

1. Life events and other Social Factors:

These factors don’t cause schizophrenia. But if a person is already predisposed to schizophrenia these factors increase the chances of developing it and compromise the long-term outcome.  These factors include

• Childhood abuse and trauma; when schizophrenic patients’ lives were observed retrospectively, it was found that they were victims of emotional, physical, or sexual abuse. Some of them experienced major trauma or major medical illness during early childhood.
• Paternal marital conflicts,
• High expressed emotions in the family.
• Social isolation; patients suffering from schizophrenia often live isolated, they have few friends, usually unmarried. This behavior may be evident even before the development of illness.

1. Drug abuse and schizophrenia;

Some drugs of abuse have a strong potential for schizophrenia. And this relationship is bilateral. That means drugs increase the risk of schizophrenia and schizophrenia patients themselves are prone to use the addictive drug. Among different drugs of abuse, cannabis is highly associated with the development of schizophrenia. It is worth mentioning that cannabis is considered less addictive as it has minimal physical dependence but its relation with schizophrenia as a causative agent is significantly established.  Similarly, the relationship between alcohol is also established especially paranoid delusions and pathological jealousy.

Types of Schizophrenia 

Below are the common types of Schizophrenia

1. Paranoid Schizophrenia

In this type, the patient has very much suspicious. He thinks that other people are against him and they are trying to harm him.  

2. Catatonic Schizophrenia

Catatonia is the behavior pattern in schizophrenia. The patient is motionless and mute. He can maintain his odd posture longer period. There is a gross decline in self-care

3. Negative Schizophrenia

In this type of schizophrenia, the patient withdraws from almost every social activity. He takes little or no interest in daily activities

4. Disorganized Schizophrenia

As the name indicates, the behavior of the patient is very disorganized. He performs bizarre actions. His thought and speech is irrelevant  

Three domains of Schizophrenia Treatment

1. Drug treatment of schizophrenia

The mainstay of acute treatment of schizophrenia is medicine. Psychotherapy is even contraindicated in the acute phase There are two main classes of drugs for schizophrenia 1. typical antipsychotics 2. atypical antipsychotics A few things need to remember regarding drug treatment for schizophrenia.

• Continue medicine for a longer period. For example in 1^st episode treatment is usually for 2 years after remission of symptoms
• These are not addictive medicines
• Like any other medicine, these are not free from side effects. But not all side effects appear in all patients.
• Even if the patient experiences side effects of medicine, there is no need to stop the medicine always. Because these side effects are reversible. The adjustment of the medicine dose can relieve the side effects. For this purpose, you need to consult your psychiatrist

 

2. Can psychotherapy be effective in schizophrenia

One of the important components of the psychological treatment of schizophrenia is to help the patient gain insight into the illness. This can be achieved when the patient has started responding to drug treatment. Common psychological interventions are

1. Cognitive behavior therapy

The use of cognitive behavior therapy is also helpful. The main principle is to challenge the delusions by structured reasoning. It is important to avoid confrontation as it can provoke aggression. During the acute phase of illness, it is difficult to challenge the delusion. So the benefits of CBT are maximum when the formation of delusion is not complete. Or there is at least a partial response with medicine. Similarly, this technique can also be used to modify the beliefs regarding the origin of hallucinations

1. Cognitive remediation

Impairment in cognitive functioning is highly important in schizophrenia. This can be part of the illness or side effects of antipsychotic medication. In this technique, the patient has to do some mental exercises to enhance their cognitive functions

3. Role of Family and social treatment in schizophrenia

Family and social circumstances also play a key role. These interventions are usually adjuvant to drug treatment which is still the main treatment option. These include education of the family regarding the illness, diagnosis, treatment options, chances of recovery, etc. Sometimes highly expressed emotions in the family also deteriorate the prognosis. These include hostility, overprotectiveness, and emotional over-involvement. These behaviors of the family need improvement. Similarly, a family can also have a major role to adhere the patient to a treatment care plan. In some cases, supported employment and work do well in this disorder.

Two important questions

1. Why it is necessary to take medicine regularly?

In schizophrenia, it is very important to continue medicines regularly for a longer period. Adherence means not only taking medicine regularly but also following the other instructions, making regular visits inform the physician regarding side effects. The importance of adherence is that it increases long-term recovery, improves the functioning of the patient, and reduces the chances of relapse. But what happens actually, is that patients usually stop medicines or reduce the dose of medicine. There can be multiple reasons for this. Sometimes patients stop medicine due to its side effects. they also think that there is no need for medicine as they are not ill. Also, their health belief models put a hindrance to treatment. For example, they may consider these symptoms supernatural. There can be different reasons for non-adherence but they are manageable.

1. Why it is necessary to start treatment early?

Research has established the fact that the longer the duration of untreated illness, the worse will be the prognosis. Another research found that a maximum decline in functioning and cognitive skills appears during the first two years of illness. So if we can start treatment early, the outcome will be better.

What is the outcome of schizophrenia after treatment?

1/5 patients have a good prognosis. They return to baseline medicine. These can be free of medicine after some time. 3/5 patients need medicine for a longer period. Although their symptoms do not fully recover, they can live and earn independently with minor support from family. 1/5 patients need long-term care and treatment. Independent living is difficult.  

Case Study:

A school teacher referred a young boy student in 10^th grade. She noticed a steady decline in her studies. According to her report, he was behaving strangely in class and during break time.  He used to remain isolated, collect pieces of newspaper and put them in his bag. His parents reported that he used to stare at walls most of the time. During the interview with the boy, he was uncomfortable and looked side by side. He reported that something forced him to do a project by some agencies. He has to decode the hidden messages. These messages are in the form of letters. In addition, he also heard the voice of a female. He described it as artificial intelligence. It gave him instructions about where to put those decoded messages. He feared that if he will not do that task, they will kill him and his family. After a detailed evaluation, his diagnosis was schizophrenia. The psychiatrist prescribed him medicine and educated the family regarding illness and the importance of taking medicine regularly. After three to four weeks his condition started improving.